Full name

Personal details

Heath information

Policy summary

$0/mth

(incl. 3% direct debit discount)

Base planmembers covered

$0/mth($0 excess)

Application summary

This page tracks your application progress. Once you have completed all the actions (indicated with an orange exclamation mark), the finish application button will become available and will progress you to a simple declaration and payment information.

You can save at any time, and we will email you a link so you can return to complete your application later. You have only 30 days from the date of your quote to complete your application, after which you will need to start again. If you have any questions or require any assistance, please contact one of the Accuro team on info@accuro.co.nz or 0800 222 876.

Applicant details

Child's details

Guardian's details

All fields required

Personal details

Name

Date of birth

Gender

Male

Female

Have you smoked in the last 12 months?

Yes

No

Are you a New Zealand resident?

Yes

No

Email

Please send me information via email rather than post if possible

Relationship to Policyholder

Policy Details

Working visa upload

No files uploaded yet

Phone

Please provide at least one contact phone number

Address

Employment industry

How did you hear about us?

Member number/name:

Please provide details:

Broker Details

Name

Code

Why do I need to provide a copy of my working visa?

To be eligible to take out Accuro's SmartStay or SmartStay+ you must have a current New Zealand working visa.

Policy summary

$0/mth

(incl. 3% direct debit discount)

Base planmembers covered

$0/mth($0 excess)

Payment method

Direct debit

Will be setup to start five days after your health insurance commences unless you state a first payment date (please note this is subject to the time it could take to complete the processing of your application).

Invoice

We will post you an invoice with your health insurance start-up pack that will need to be paid within 7 days.

First payment date

If you have a preference please let us know otherwise we will start payments five days after issuing your policy. Please note: your first payment date cannot be after the 28th of the month.

Your quote has been saved

Thank you for completing a quote with Accuro Health Insurance. This quote will be valid for 30 days. If you wish to continue, make sure that you complete your application by XX MONTH 20XX.

Please note that if you have a birthday before your policy is issued, the pricing will be affected.
We have sent you an email with a link back to your quote. To return, simply click the link in the email and you can continue editing. You can save and return to your quote as many times as you need.

If you have any questions or require any assistance, please contact one of the Accuro team on info@accuro.co.nz or 0800 222 876. We are happy to help.

Your application has been saved

Thank you for starting an application with Accuro Health Insurance - This application will be valid for 30 days from Fri Sep 04 2015. Please make sure that you complete your application by XX MONTH 20XX.

Please note that if you have a birthday before your policy is issued the pricing will be affected.

We will send you an email containing a link to your application so you can return to it when you are ready to continue.

If you have any questions or require any assistance, please contact one of the Accuro team on info@accuro.co.nz or 0800 222 876. We are happy to help.

SmartCare

Nothing is more important than your health. Without your health, your lifestyle and earning ability can be impacted. Much of the emotional and financial burden of an illness can be avoided by protecting yourself and your loved ones with health insurance.

Who is the policyholder?

Policy declaration

Declaration and authorisation to obtain and use information

I, the person applying for this Accuro Health Insurance policy confirm that I:

Agree that this application and any other information obtained/provided about persons to be included on my plan forms the basis of the contract.

Declare that the information I have given is correct and complete and that no material fact has been omitted. I undertake to advise Accuro Health Insurance of any health condition or event that may affect any of the people named in this application or any relevant information that may affect the policy between the date I sign this application and the date the policy commences with Accuro Health Insurance.

I am legally responsible for the named children and declare that any information supplied in this application, whether written by me or not, is true and accurate, and that I am authorised, where any person insured is less than 16 years of age, to act on their behalf.

Have read and understand this declaration and authorisation and its applicability to the Privacy Act 1993 and Health Information Privacy Code 1994 (see below for further information).

Understand the nature of the plan(s) chosen and believe they meet my/our requirements.

Understand that, upon issuance of the membership certificate, I have fourteen (14) days to cancel my/our plan(s) ('14-day free-look' period) and that, subject to no claims having been made, the person who paid the premium will receive a full refund.

Understand that, if the application is approved, cover will start from the date stated on the membership certificate issued by Accuro Health Insurance.

For the purpose of assessing this application and any future claims, authorise Accuro Health Insurance to request and obtain information and records about named children and any other people in this application. I authorise the following people to give you any such information and records:
Any doctor, medical specialist, health agency, hospital, the Accident Compensation Corporation or other relevant person, including any other insurance held in respect to a named child.

Privacy Act 1993 and Health Information Privacy Code 1994

Each person applying for this Accuro Health Insurance plan should please note the following:

This proposal collects personal information about you and each other person named in this plan in connection with the insurance that is sought.

The intended recipient of that personal information is Accuro Health Insurance.

You have the right to access and request corrections subject to the provisions of the Privacy Act 1993. This information will be held at our head office.

While Accuro Health Insurance intends to treat this information as confidential, there are some situations where we may need to disclose your personal information to a third party.

By signing this declaration, you authorise the disclosure of the personal information of each person named in this plan (including any children) to third parties and any other person named in the plan:

for statistical purposes (where not individually identified)

for evaluation and assessment of claims under the policy that result from this application

for providing on-going client service and information

for any other matter related to the policy.

By accepting and submitting this application, you also authorise Accuro Health Insurance or any agency authorised by Accuro Health Insurance to give and obtain any personal information including any child's medical records, from other insurers and from medical practitioners. You agree this may include information relating to any other insurance applied for or obtained or claims previously made by you.

Important information

This form represents an application by the guardian signing this declaration to become an associate member of Accuro Health Insurance and relates only to the plan(s) indicated.

Anything in this declaration purporting to the singular may, by inference, include the plural.

Accuro Health Insurance is the trading name of the Health Service Welfare Society Limited (as registered under the Industrial and Provident Societies Act 1908). By making this application, you are accepting the rules of the Society, including obligations therein, and understand that the rules may subsequently be changed. If you would like a copy of the current rules before making this application, please do not hesitate to ask.

Accuro Health Insurance is also a registered financial service provider under the Financial Service Providers (Registration and Dispute Resolution) Act 2008.

The Board of Directors of the Society reserves the right, at all times, to vary the terms and conditions and benefits of plans however it deems appropriate.

This application forms the basis of any contract that eventuates and must be completed truthfully and accurately. Applicants are obliged, beyond that which is requested, to volunteer information that would have a material impact on the cover offered. If you have doubts, you should disclose the information to Accuro Health Insurance for determination of significance.

Premiums are subject to change on 21 days’ notice.

I acknowledge the information provided in this declaration, including in relation to my/our privacy, and accept the terms and conditions (including the limitations and exclusions) of the policy, including Accuro Health Insurance General Policy Terms and Conditions.

Please be aware that you are required to advise Accuro Health Insurance of any new signs/symptoms or health condition for any applicant that arises between the date you sign the application form and the date the policy commences.

Remove member

Conditions of this authority to accept direct debits

1. The Initiator:

(a) Will not initiate a direct debit on my/our account unless authorisation is received from me/us in accordance with the terms and conditions agreed between me/us and the Initiator of each amount to be debited from my/our account.

(b) Has agreed to send notice of the net amount of each direct debit and the due date of debiting after receiving authorisation from me/us under clause 1 (a) but no later than the date the direct debit will be initiated. This notice must be provided in writing (including by electronic means and SMS where the Customer has provided prior written consent (including by electronic means including SMS) to communicate electronically). The notice will include the following message: 'The amount $''' was directly debited to your Bank account on (initiating date).'

OR

(a) Has agreed to give advance notice of the net amount of each direct debit and the due date of the debiting at least 10 calendar days (but not more than two calendar months) before the date when the direct debit will be initiated. This notice will be provided in writing (including by electronic means and SMS where the Customer has provided prior written consent (including by electronic means including SMS) to communicate electronically). The advance notice will include the following message: 'Unless advice to the contrary is received from you by (date*), the amount of $''' will be directly debited to your account on (initiating date).' * This date will be at least two (2) days prior to the initiating date to allow for amendment of direct debits.

(b) May, upon the relationship that gave rise to this Authority being terminated, give notice to the Bank that no further direct debits are to be initiated under the Authority. Upon receipt of such notice, the Bank may terminate this Authority as to future payments by notice in writing to me/us.

(c) May, upon receiving written notice (dated after the date of this Authority) from a bank to which I/we have transferred my/our Bank account, initiate direct debits in reliance of that written notice and this Authority from the account identified in the written notice.

2. The Customer may:

(a) At any time, terminate this Authority as to future payments by giving written notice of termination to the Bank and to the Initiator.

(b) Stop payment of any direct debit to be initiated under this Authority by the Initiator by giving written notice to the Bank prior to the direct debit being paid by the Bank.

(c) Where a variation to the amount agreed between the Initiator and the Customer from time to time to be direct debited has been made without notice being given in terms of 1(a) above, request the Bank to reverse or alter any such direct debit initiated by the Initiator by debiting the amount of the reversal or alteration of the direct debit back to the Initiator through the Initiator's Bank, PROVIDED such request is made not more than 120 days from the date when the direct debit was debited to my/our account.

3. The Customer acknowledges that:

(a) This Authority will remain in full force and effect in respect of all direct debits passed to my/our account in good faith notwithstanding my/our death, bankruptcy or other revocation of this Authority until actual notice of such event is received by the Bank.

(b) In any event this Authority is subject to any arrangement now or hereafter existing between me/us and the Bank in relation to my/our account.

(c) Any dispute as to the correctness or validity of an amount debited to my/our account shall not be the concern of the Bank except in so far as the direct debit has not been paid in accordance with this Authority. Any other disputes lies between me/us and the Initiator.

(d) Where the Bank has used reasonable care and skill in acting in accordance with this Authority, the Bank accepts no responsibility or liability in respect of:

' the accuracy of information about direct debits on Bank statements; and

' any variations between notices given by the Initiator and the amounts of direct debits.

(e) The Bank is not responsible for, or under any liability in respect of the Initiator's failure to give notice in accordance with 1(a) nor for the non-receipt or late receipt of notice by me/us for any reason whatsoever. In any such situation, the dispute lies between me/us and the Initiator.

4. The Bank may:

(a) In its absolute discretion conclusively determine the order of priority of payment by it of any monies pursuant to this or any other Authority, cheque or draft properly signed by me/us and given to or drawn on the Bank.

(b) At any time terminate this Authority as to future payments by notice in writing to me/us.

(c) Charge its current fees for this service in force from time to time.